Sleep. Medicine. Music. Life.

Tag Archives: insomnia

Post navigation

Don’t you love summer? All the barbecues, outdoor festivals, vacations; school’s out, with all the freedom that goes with that.

I love summer as much as the next guy. Many of my sleep patients don’t, however. I’ve found that there are a couple of times of the year in which my patients experience a spike in their insomnia: during the holidays, and during the summer.

There are several reasons why summertime can trigger or worsen difficulties falling and/or staying asleep. First, many people and many families experience lifestyle changes during the summer as compared to during other times of the year: kids can sleep in in the morning; vacations with jet lag; modifications in work hours or work timing; late-night parties and alcohol use. These changes tend to dysregulate sleep schedules, leading to insomnia. Second, it’s hot! It’s hard to sleep when you’re sweltering and sweating in bed every night; we here in Seattle have been in a month-long heatwave, a major problem because most homes here have no air conditioning! Third, because of the tilt of Earth’s axis during the summer, it’s light out late. As most can easily understand, if the sun is still up in the evening, it feels naturally for YOU to stay up. Exposure of your eyes–and hence your brain–to light has a profound impact on your sleep/wake cycles. No wonder why people tend to have insomnia during these precious summer months!

So here are some pointers to improve your sleep for the remainder of this summer:

1. Choose a time to awaken each morning, and stick with it. Even if you’re not in school or not working, determine a preferred awakening time, set your alarm clock or smart phone for that time, and awaken and get out of bed that same time every morning, including weekends. Your body clock “wants” regularity, no matter what your personal situation. Sleeping in by several hours can throw off your body’s circadian rhythms, dysregulate your sleeping patterns, and promote delayed sleep phase.

3. Keep your sleeping environment QUIET. Whether it’s motorcyclists or firecrackers outside your bedroom window, summertime often means lots of noise outside your bedroom. Insulate your bedroom from the noise the best you can. A fan near the bed can create a white-noise effect to drown out noises from outside. Some may resort to sleeping in another, quieter room in the home, one that is further away from the street for example.

4. Keep your sleeping environment COOL. The fan in the room helps with this, obviously, if you don’t have AC.

5. Avoid naps if you can. Naps are tempting if you have the time and opportunity, particularly if you’re chronically sleep-deprived. However, naps during certain times of the day–particularly the mid- to late afternoon–can cause substantial subsequent problems falling asleep later at night.

6. Don’t spend too much time in bed. Remember, most adults need about 7-8 hours of sleep per night, and your body generally won’t let you sleep more than what your body needs.

School is starting back up before you know it. Enjoy the remainder of your summer!

A cold, bitter rain is falling in Seattle this morning, not the misty, spitting kind we often get in the Pacific Northwest in the middle of winter, but the big-droplet, drenching sort, rain that soaks your clothes, makes you shiver, and causes your kids to catch cold.

The weather reflects our collective mood in Seattle today, as we struggle to process what happened at the very end of last night’s Superbowl XLIX, in which the Seattle Seahawks battled the New England Patriots for the NFL championship and the Lombardi trophy. In the final seconds of the final quarter, with the Seahawks in possession of the ball, second down and goal, mere feet from the Patriots’ end zone, Quarterback Russell Wilson threw the football instead of giving it to a running back (i.e., “Beastmode” Marshawn Lynch) for a rushing play. As most everyone knows now, that final play didn’t go very well, resulting in a Patriots interception that sealed the win for Brady and Co. and hammered the final nail in the coffin for our Seahawks.

I am doing my best not to turn this post into a commentary about that play, Coach Pete Carroll’s decision-making, and the resulting outcome of the game. But I will share here that I experienced some, shall we say, emotional intensities in response to Carroll’s authorization to throw that ball, something that surely would have been lauded as a “brilliant play” and a “gutsy move” had it resulted in a touchdown. Those intense emotions led to . . . you guessed it . . . some sleep-maintenance insomnia last night. I woke up at 3:16 a.m. and it took a while for me to fall back to sleep. I’m not alone in this misery. I’m sure there were a lot of people awake last night throughout the Puget Sound area, and not because of celebrating. Earlier this morning some colleagues and I were talking about the game in our doctors’ lounge, and my hand surgeon friend told me he had awakened at 3:30 himself! I strongly suspect Carroll has a number of sleepless nights ahead of him as well.

People tend to awaken in the middle of the night in the setting of intense emotions, particularly negative or traumatic ones. This phenomenon is called early morning awakening. Early morning awakening is part of the human condition: we all experience emotional peaks and valleys as we move through life, and most everyone has had an occasion or two to awaken in response to the peaks and valleys. Sounds familiar, doesn’t it? The driver of the problem (in my case, that crazy throw) is the first thing you think about when you abruptly awaken, almost as if you had been thinking about it somehow prior to your awakening, and you turn the thing over in your head, ruminating about what went wrong, setting up all kinds of alternative scenarios, going through the “what if’s,” . . . right? All of those thoughts and emotions have a stimulating effect, which tends to prolong awake time once aroused from sleep.

What I’m describing is a reactionary or situational form of insomnia which, again, in many respects is simply a result of human nature. The good news is that in many or most cases, this temporary problem eventually (and usually quickly) fades and resolves as the intensity of whatever it is that you’re ruminating over fades (for us Seahawks fans, the sooner last night’s game is pushed toward the back of the vault of football history the better). However, in some cases, particularly for those with suboptimal baseline sleep habits (poor sleep hygiene), this insomnia can snowball into something more substantial and chronic, called psychophysiologic insomnia, which may benefit from medical attention if severe, sustained, or problematic enough.

I’m sure the intensity of the moment will start fading shortly for me as I delve into this week’s work, but this morning I admit I’m a little bleary-eyed and upset, which is why I was in the doctors’ lounge getting some coffee and commiserating about our loss. Next year should be a great one. Watch out for the Seahawks in 2015-16!

All you parents know what’s right around the corner, if it hasn’t already happened: the start of the new school year!At least for us in the Pacific Northwest, school doesn’t start for another week, so we have one more glorious week of sun and freedom before the beginning of fall classes. But for many of you elsewhere, school has already started in earnest.

One of the many concerns parents have as they transition back into the school year is how their children’s sleep habits will change. Many of us know the drill, from our children’s experiences or our own: all the staying up late on weekends, sleeping in ’til noon on Saturdays and Sundays, the Herculean effort necessary to get out of bed in the morning, especially on Mondays. Though this ritual is very common, particularly for teenagers, the stress and conflict arising from this chronic problem can wreck your family life, not to mention your grades.

This pattern, called delayed sleep phase, arises from the adolescent brain’s natural tendency to cycle its sleep-wake rhythms in a timing scheme that is longer than the 24-hour day. Many of us recall what it was like to be younger and wanting to stay up later and sleep in later if given the chance. The problem with this tendency is that children and teenagers usually engage in activities (i.e., school) that obligate them to entrain their sleep-wake behavior to the 24-hour clock. This conflicts with their biological inclination to go to bed later, resulting in sleep deprivation which makes it more difficult to awaken early in the morning and be awake and alert for classes. Friday night comes ’round, they stay up late, sleep in big-time on weekend days, and then find it impossible to fall asleep early Sunday night because their body clock’s sleep-wake phase has now been delayed from all the sleeping in, so all the sleep debt and sleep deprivation then roll into the new school week, perpetuating the cycle.

There is ongoing controversy about what can and should be done to improve this problem for young people and their families. Though some schools around the country have options of starting classes later in the day, many or most of us parents are obliged to ensure that our children are out of bed and ready for school at times earlier than what they, and their body clocks, “want.”

So what can be done? We can’t change our kids’ brains, though sometimes it’d be great if we could, right? Here are a few tips to help weary parents get their kids sleeping better as we kick off this new school year. As you will see below, these recommendations may be quick to read and absorb, but whether they are easy is another matter. The unfortunate reality is that making these sleep problems substantially better likely will be difficult, at least at first, requiring communication, motivation and insight from the child and patience and support from the parent. Ready? Here goes.

1. Minimize the “sleeping in” on non-school days by setting the alarm clock for reasonably similar times each day to the extent you can. Kids hate this most of all. Sleeping in dysregulates your body clock, causing nocturnal insomnia and daytime fatigue. Sleep schedule dysregulation is why we have jet lag, for example. If your child has to awaken for school at 6 a.m., say, but sleeps in ’til noon on weekends, and then tries to go to sleep early Sunday night, such abrupt changes in the brain would be the equivalent of flying from the west coast to the Bahamas, for example, and back, every week. Regulating the wake-up time may well require a hard sell to the teenager; I’d rather the teen sleep in until 8 a.m. than until noon. This lifestyle modification (and it’s a big one) gets substantially easier if done diligently for a couple weeks, but I won’t lie, it’ll be painful for all involved at first. The child may need some, er, parental assistance in getting up on weekends. A second alarm clock is also an option. Put one alarm clock on the nightstand, and then put the second one further away, set for 2 minutes after the first clock, so that your teen will need to physically get out of bed to turn it off. Make sure the second alarm clock is loud, and the more obnoxious the better.

2. Don’t go to bed until substantially sleepy. If the first step is done properly and done the same way every day, then this second step should fall naturally into place eventually, because the resulting sleep deprivation should make your teen become drowsy gradually earlier in the evening on weekends. Force your child to go to bed too early, however, and residual insomnia results. Taking advantage of children’s sleep needs allows them to fall asleep quickly and earlier (including on Sunday nights) and at the same time get proper amounts of sleep (which for children and teens can be 9-10 hours per night), both of which are important in physical and cognitive development and proper performance in school.

3. Declare a curfew from light and technology. Light exposure greatly impacts our levels of wakefulness and alertness; add to this the perceived need to always be constantly “plugged in” socially through mobile devices, and you have a recipe for “up all night.” Shield your child’s bedroom from outside light and noise, such as with black thick curtains, particularly as these summer months continue to wane. Start dimming your home’s ambient light several hours prior to the projected bedtime. And, finally and importantly, I recommend laying off lit-screen gadgets (including iPads, laptops, and smart phones) 2-3 hours prior to the projected bedtime.

Now that I think about it, I’m pretty sure this last recommendation is actually what kids hate the most. But complete these 3 steps, and utilize them consistently, and chances are your child will sleep better.

Shortly I’ll be on a plane to Wichita, Kansas, for my high school reunion. Every time I step foot on Kansas soil a flood of great memories returns: Friday night football games, Knolla’s Pizza, midnight movies, parties, Bionic Burger, the River Festival, Galaga, and, especially around this time of year, the all-important beginning of summer.

Where I grew up, summer was all about crowded public swimming pools, Dairy Queen Hot Fudge Brownie Delights, baseball, mowing a huge yard all day every Saturday, hay fever, washing dishes at a restaurant by day, dragging Douglas by night, and listening to the Police and Marillion in my little green 2002. It was also about hanging out with my friends, and to be perfectly honest I often didn’t sleep as much as I should have. What did I know? Sleep deprivation and sleeping in were pretty common during the sweltering, humid summer months of my teenage years.

Sleep often suffers in the summertime. So before I depart I will leave you with some quick, easy tips to make your sleep easier, better, and more enjoyable during these hot summer months.

1. Keep your bedroom dark, quiet, and cool. Insulate your room and windows from noise and light to the extent that you can. It’s a tough time for many of us financially, but if you are unable to sleep because the room is hot, use your air conditioning; sleeping well is worth the money spent on utilities. If you can’t fix your hot, light, loud bedroom, try sleeping in the basement.

2. Strive to keep your sleep schedules regular. School’s out; loved ones are visiting; the neighborhood BBQ is in full swing; you’re off on a family vacation. There is always the temptation to party late, sleep in, and not set your alarm clock during the summer. Your body clock doesn’t care about any of that, however. A common cause of insomnia and daytime sleepiness is dysregulation of sleep schedules. Continue to awaken around the same time every morning (if you don’t have to awaken at any one specific time, you would do well to choose a preferred awakening time and stick with it), including on weekends and non-work days.

3. Mind your late-night alcohol. Alcohol has sedative effects for the first couple hours after you ingest it. However, after several hours it tends to be a sleep disrupter.

4. If you’re a night shift worker, get thick black curtains for your bedroom windows and wear dark sunglasses on your way home from work in the early morning. Remember: it’s light out early in the morning and late in the evening when it’s summertime, so your brain can be tricked into making you feel more awake and alert if there is bright light exposure around the time that you should be sleeping.

5. Avoid late-night exercise. The release of stimulatory hormones when you exercise hard can last for several hours, causing insomnia. I recommend that you stop heavy aerobic activity 2-3 hours prior to your projected bedtime.

6. Take care of yourself. Don’t sacrifice your health for all that summertime fun. Obviously, anything that causes physical discomfort can be a detriment to your sleep. Avoid sunburns and dehydration. Use nasal sprays or see your doctor for those seasonal allergies. Minimize hangovers. Don’t overextend yourself. And, as I will probably see firsthand this weekend, it’s best to remember you’re not in your 20’s when you’re, uh, no longer in your 20’s, just ’cause it’s summer.

Utilize these simple suggestions and chances are you likely you’ll be able to avoid a . . .

The American Academy of Sleep Medicine (AASM) has declared today, March 10, Insomnia Awareness Day this year. The timing of this auspicious occasion is in keeping with the daylight savings time change from over the weekend.

We in sleep medicine circles call today “Black Monday,” the first workday following the one-hour time change each spring. Our body clocks don’t like making changes in their sleep shifts, even if only by a mere hour; anyone who has experienced jet lag knows what I mean. As you know, “springing forward” one hour means having to get up one hour earlier than what our body clocks are accustomed to and thus “prefer.” For those who do not adjust their bedtime schedules accordingly, getting up to get to work, school, or appointments on Black Monday becomes all the more difficult. At the same time, the mild dysregulation of sleep scheduling can also lead to insomnia, particularly if there is already baseline insomnia to begin with.

I’ve covered insomnia in previous posts, and I will go over it and its management in future posts too, because it is such a huge, prevalent clinical problem and growing public health concern. For the purposes of today’s Insomnia Awareness Day post, however, I will concentrate simply on what insomnia means.

The definition of insomnia, as accepted by the AASM, is the “subjective perception of difficulty with sleep initiation, duration, consolidation, or quality that occurs despite adequate opportunity for sleep, and that results in some form of daytime impairment.” [Schutte-Rodin S; Broch L; Buysse D; Dorsey C; Sateia M. Clinical guideline for the evaluation and management of chronic insomnia in adults. J Clin Sleep Med 2008;4(5):487-504].

As such, insomnia is by its very nature subjective, meaning that you can have insomnia no matter how much actual sleep you really get, and implying that the time spent awake in bed is bothersome. Among the many impairments associated with insomnia are a feeling of unrefreshing sleep, low energy levels during the day, daytime sleepiness, emotional problems (like depression and anxiety), morning headaches, difficulties with memory and concentration, reduced work productivity, and a propensity toward industrial and motor vehicle accidents.

This definition is important. You can have insomnia even if you get a full 8 hours of sleep each night (such as if you are spending 12 hours trying to sleep each night). Conversely, 4 hours spent in bed spent awake each night casually watching television but not trying to sleep do not constitute insomnia. Note also that the definition does not address potential causes, of which there are hundreds–causes can range from a can of Mountain Dew at 10 p.m. to one’s mental perception of dread and frustration associated with previous difficulties falling asleep. The definition of insomnia also helps provide a rough roadmap to therapy. My own practice philosophy for patients with chronic insomnia (i.e., insomnia that lasts for a month or longer) is to identify the underlying causes and to improve the insomnia by improving or resolving the problems causing it.

From a clinical perspective, chronic insomnia management can range from relatively straight-forward to extremely challenging. Doctors that identify themselves as “physician sleep specialists” should have the expertise and willingness to handle cases of insomnia, including the tough ones. Enlist their help should your insomnia become sufficiently problematic. Help IS available.

Last week we were bombarded by the media over the controversy surrounding New Jersey Governor Chris Christie‘s staff and “Bridgegate.” During his recent press conference regarding this matter, Christie indicated at 2:27 in this video clip below, “I haven’t had a lot of sleep the last two nights, and I’ve been doing a lot of soul-searching.”

I want to make clear this is not in any way a political post, and is not intended to defend or criticize Christie or anyone else. I present this here simply to illustrate one generally well-understood point, which is that emotionally significant life events–whether they be good or bad–commonly cause difficulties sleeping.

There are several potential reasons for this. First, problematic life events–such as Christie’s–are often accompanied or followed by mood problems and anxiety, both of which can cause difficulties falling and staying asleep. Depression is commonly associated with insomnia–in particular a phenomenon called “early morning awakening,” in which the depressed person tends to awaken spontaneously several hours earlier than the normal or desired time, with very substantial problems returning to sleep. Second, anything that you think about in bed that is of emotional value can cause difficulties sleeping, because those thoughts have a stimulating effect which makes you more awake and alert. The more intense the emotions or concerns (I suppose that would include “soul-searching”), the more psychologically and physically stimulated you can get (an extreme example might be the feeling of sweating and heart-pounding upon hearing devastating news), and this stimulation can cause your insomnia to snowball.

OK, I will add just one brief, slightly political point here. I wish people in the media would stop calling Christie fat and teasing him for it. I NEVER use this term in my clinic or socially to refer to one’s weight. Plus, he’s lost a substantial amount of weight following his gastric lap band surgery last year. I’ve heard several Christie “fat jokes” on national radio and television programs in the past week. Really? Come on, folks, let’s at least be civil, yeah?

Anyhow, in a completely different matter, Pete Carroll, head coach of the Seattle Seahawks, said in a television interview last week that he hasn’t been sleeping much lately either, but that’s probably because of how crazy his schedule must be right now in addition to the excitement of prepping his team for the playoffs and, now, Sunday’s NFC championship game! There must be some anticipatory anxiety, for sure, and this kind of emotion certainly can lead to sleepless nights as well, though for reasons quite different from (and in many ways the opposite of) Christie’s. And hopefully–understand, I live in Seattle–he won’t have any sleepless nights due to game losses in the next several weeks!

Finally, continuing with the football theme, I will leave you today with this recent video clip of ESPN analyst and former Chicago Bears coach Mike Ditka dozing while on air during ESPN’s Sunday NFL Countdown Show. Keyshawn Johnson had to nudge him awake! Glad Coach was behind a desk and not behind the wheel at the time.

I have no idea what the circumstances were that led to Ditka’s on-air snooze. Maybe he was watching George Wendt‘s State Farm commercials over and over late the previous night.

I’m a proud dad today. Yesterday my boys both ran their first 5K race. One, who turns 12 next March, outran me by an entire minute! I’ve told my boys for years now that one of my goals is for them both to end up being better than me at everything, and that’s starting to happen now!

A lot has been made of the relationship between exercise and quality of sleep over the years. Recently, the 2013 National Sleep Foundation Sleep in America poll demonstrated “a compelling association between exercise and better sleep.” Paraphrasing the data, those polled who did not exercise regularly indicated their sleep quality was “very bad” as compared to those who exercised regularly by a substantial margin: 14% as compared to 3-4%. In addition, 76-83% of those who exercised regularly felt their sleep quality was “very good” or “fairly good,” as compared to 56% of those who did not exercise regularly, despite insignificant differences in sleep duration between the two groups. These data and additional data from the poll support the longstanding idea of an association between good sleep habits and a lifestyle involving regular exercise.

We all know that regular exercise has been associated with improved overall health across a wide spectrum of parameters, ranging from cardiovascular fitness to mood. Here are a couple simple exercise tips as pertains to your sleep:

1. Exercise in the morning in general can help sleep quality and reduce the amount of time it takes to fall asleep once in bed at night.

2. Though the notion of whether late-night exercise is detrimental to sleep has been challenged in recent years, I still recommend to my patients that it’s likely best to avoid intense aerobic exercise within 1-2 hours prior to their projected bedtimes; heavy aerobic activity can promote the release of stimulatory hormones.

3. Considerexercise outdoors early in the morning. The combination of aerobic activity and light exposure early in the day can further increase levels of wakefulness during the day and quality of sleep at night.

4. Keep in mind: the promotion of great sleep habits and hygiene originates from the same mindset that generates a schedule that includes regular exercise: discipline to maintain a lifestyle geared toward good health, happiness, and longevity. Use the same discipline for your sleep as you do to get yourself to the gym. Stay regular with your sleep times and sleep scheduling. Awaken around the same time every morning to the extent that you can.

5. Your exercise tolerance and energy levels probably will improve with proper amounts of sleep every night! Obey your body’s intrinsic need for sleep; most adults require around 7.5-8 hours of sleep per night, regularly, to feel fully awake and alert during the day.